CHAPTER 10 - COVERED SERVICES REQUIREMENTS
10.1 – MEDICAL RECORD STANDARDS
The medical record contains clinical information pertaining to a member’s physical and behavioral
health. Maintaining current, accurate, and comprehensive medical records assists providers in
successfully treating and supporting member care.
Providers must maintain legible, signed and dated medical records in paper or electronic format that are
written in a detailed and comprehensive manner, conform to good professional practices; permit
effective professional review and audit processes; and facilitate an adequate system for follow-up
treatment.
PAPER OR ELECTRONIC FORMAT
Paper medical records and documentation must include:
• Date and time;
• Signature and credentials;
• Legible text written in blue or black ink or typewritten;
• Corrections with a line drawn through the incorrect information, a notation that the incorrect
information was an error, the date when the correction was made, and the initials of the person
altering the record. Correction fluid or tape is not allowed; and
• If a rubber-stamp signature is used to authenticate the document/entry, the individual whose
signature the stamp represents is accountable for the use of the stamp. A progress note is
documented on the date that an event occurs. Any additional information added to the progress
note is identified as a late entry.
Electronic medical records and documentation must include:
• Safeguards to prevent unauthorized access:
o The date and time of entries in a medical record as noted by the computer’s internal clock;
o The personnel authorized to make entries using provider established policies and procedures;
o The identity of the person making an entry; and
o Electronic signatures to authenticate that a document is properly safeguarded and the
individual whose signature is represented is accountable for the use of the electronic
signature.
Electronic medical records and systems must also:
• Ensure that the information is not altered inadvertently;
• Track when, and by whom, revisions to information are made; and
• Maintain a backup system including initial and revised information.
TRANSPORTATION SERVICES DOCUMENTATION
• For providers that supply transportation services for recipients using provider employees (i.e.
facility vans, drivers, etc.) the following documentation requirements apply:
o Complete service provider’s name and address;
o Signature and credentials of the driver who provided the service;
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Vehicle identification (car, van, wheelchair van, etc.);
Members’ Arizona Health Care Cost Containment System (AHCCCS) identification number;
Date of service, including month day and year;
Address of pick up site;
Address of drop off destination;
Odometer reading at pick up;
Odometer reading at drop off;
Type of trip – round trip or one way;
Escort (if any) must be identified by name and relationship to the member being transported;
and
o Signature of the member, parent and/or guardian/caregiver, verifying services were rendered.
If the member refuses to sign the trip validation form, then the driver should document
his/her refusal to sign in the comprehensive medical record.
For providers that use contracted transportation services, for non-emergency transport of
recipients, that are not direct employees of the provider (i.e. cab companies, shuttle services,
etc.) see Policy 201, Covered Services for a list of elements recommended for documenting nonemergency transportation services.
It is the provider's responsibility to maintain documentation that supports each transport
provided. Transportation providers put themselves at risk of recoupment of payment IF the
required documentation is not maintained or covered services cannot be verified.
Health Choice Integrated Care communicates documentation standards listed in Chapter 4.0,
Covered Services to their contracted providers.
DISCLOSURE OF RECORDS
All medical records, data and information obtained, created or collected by the provider related to
member, including confidential information must be made available electronically to Health Choice
Integrated Care, AHCCCS or any government agency upon request.
When a recipient changes his or her PCP, the provider must forward the member's medical record or
copies of it to the new PCP within ten (10) business days from receipt of the request for transfer of
the record.
Behavioral health records must be maintained as confidential and must only be disclosed
according to the following provisions:
• When requested by a member’s primary care provider (PCP) or the member’s Department of
Economic Security/Division of Developmental Disabilities/Arizona Long-Term Care System
(DES/DDD/ALTCS) support coordinator, the behavioral health record or copies of behavioral health
record information must be forwarded within ten (10) days of the request. (See Chapter 11.1,
Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers
for more information; see the ADHS/DDD Interagency Service Agreement Amendment 9).
• Health Choice Integrated Care and subcontracted providers must provide each member who makes a
request one copy of his or her medical record free of charge annually.
• Health Choice Integrated Care and subcontracted providers must allow, upon request, recipients to
view and amend their medical record as specified in 45 C.F.R. § 164.524, 164.526 and A.R.S. § 122293.
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COMPREHENSIVE CLINICAL RECORD
Health Choice Integrated Care shall ensure the development and maintenance of a comprehensive
clinical record for each recipient. Comprehensive clinical records, whether electronic or paper, should
contain all information contributed by any service provider involved with the care and treatment of the
member.
The comprehensive clinical record must include the following information to the fullest extent possible:
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Member identification information on each page of the record (i.e., recipient’s name and
AHCCCS /Client Information System (CIS) identification number);
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Identifying demographics including member’s name, address, telephone number, AHCCCS
identification number, gender, age, date of birth, marital status, next of kin, and, if applicable,
guardian or authorized representative;
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Initial history for the member that includes family medical/behavioral health history, social
history and laboratory screenings (the initial history of a member under age 21 should also
include prenatal care and birth history of the mother while pregnant with the member;
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Past medical/behavioral health history for all members that includes disabilities and any previous
illnesses or injuries, smoking, alcohol/substance abuse, allergies and adverse reactions to
medications, hospitalizations, surgeries and emergent/urgent care received;
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Current presenting concerns; and
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Any review of behavioral health record information by any person or entity (other than members
of the clinical team) that includes the name and credentials of the person reviewing the record,
the date of the review, and the purpose of the review.
PHYSICAL HEALTH INFORMATION
All providers must adhere to national medical record documentation standards. Below are the
minimum medical record documentation and coordination requirements. The following requirements
are taken directly from the AHCCCS Medical Policy Manual 940.1:
• Member identification information on each page of the medical record (i.e., name or AHCCCS
identification number);
• Documentation of identifying demographics including the member’s name, address, telephone
number, AHCCCS identification number, gender, age, date of birth, marital status, next of kin, and, if
applicable, guardian or authorized representative;
• Initial history for the member that includes family medical history, social history and preventive
laboratory screenings (the initial history for members under age 21 should also include prenatal care
and birth history of the member’s mother while pregnant with the member);
• Past medical history for all members that includes disabilities and any previous illnesses or injuries,
smoking, alcohol/substance abuse, allergies and adverse reactions to medications, hospitalizations,
surgeries and emergent/urgent care received;
• Immunization records (required for children; recommended for adult members if available);
• Dental history if available, and current dental needs and/or services;
• Current medical and behavioral health problem list;
• Current physical and behavioral health medications;
• Current and complete EPSDT forms (required for all members age 18 through 20 years)
• Documentation in the comprehensive medical record must be initialed and dated by the member's
PCP, to signify review of diagnostic information including:
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o Laboratory tests and screenings
o Radiology reports
o Physical examination notes
o Other pertinent data;
Reports from referrals, consultations and specialists;
Documentation that reflects assessments, requests, referrals and issuance of medically necessary
medical supplies, durable medical equipment and orthotic/prosthetic devices;
Emergency/urgent care reports;
Hospital discharge summaries;
Behavioral health referrals and services provided, if applicable, including notification of behavioral
health providers, if known, when a member’s health status changes or new medications are
prescribed;
Behavioral health history;
Documentation as to whether or not an adult member has completed advance directives and
location of the document;
Documentation related to requests for release of information and subsequent releases; and
Documentation that reflects that diagnostic, treatment, and disposition information related to a
specific member was transmitted to the PCP and other providers, including behavioral health
providers, as appropriate to promote continuity of care and quality management of the member’s
health care.
BEHAVIORAL HEALTH RECORD
For General Mental Health/Substance Abuse (GMH/SA), the comprehensive medical record must
contain the following elements:
• Intake paperwork documentation that includes:
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For members receiving substance abuse treatment services under the Substance Abuse
Block Grant (SABG), documentation that notice was provided regarding the recipient’s
right to receive services from a provider to whose religious character the recipient does
not object to (see Chapter 2.9 – Special Populations);
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Documentation of recipient’s receipt of the Member Handbook and receipt of Notice of
Privacy Practice; and
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Contact information for the member’s PCP if applicable.
• Assessment documentation that includes:
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Documentation of all information collected in the behavioral health assessment, any
applicable addenda and required demographic information (see Chapter 2.2 – Referral
and Intake Process, Chapter 2.4 – Assessment and Service Planning and Chapter 18.0 Enrollment, Disenrollment and Other Data Submission);
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Diagnostic information including psychiatric, psychological and medical evaluations;
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Copies of Notification of Persons in Need of Special Assistance (see Chapter 2.12 –
Special Assistance for Persons Determined to have a Serious Mental Illness.
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An English version of the assessment and/or service plan if the documents are completed
in any other language other than English; and
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For members receiving services via telemedicine, copies of electronically recorded
information of direct, consultative or collateral clinical interviews.
• Treatment and service plans documentation that includes:
o The recipient’s treatment and service plan;
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o Child and Family Team (CFT) documentation;
o Adult Recovery Team (ART) documentation; and
o Progress reports or service plans from all other additional service providers.
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Progress notes documentation that includes:
o Documentation of the type of services provided;
o The diagnosis, including an indicator that clearly identifies whether the progress note is for a
new diagnosis or the continuation of a previous diagnosis. After a primary diagnosis is
identified, the person may be determined to have co-occurring diagnoses. The service
providing clinician will place the diagnosis code in the progress note to indicate which
diagnosis is being addressed during the provider session. The addition of the progress note
diagnosis code should be included, if applicable;
• The date the service was delivered;
o Duration of the service (time increments) including the code used for billing the service;
o A description of what occurred during the provision of the service related to the recipient’s
treatment plan;
o In the event that more than one provider simultaneously provides the same service to a
recipient, documentation of the need for the involvement of multiple providers including the
name and roles of each provider involved in the delivery of services;
o The recipient’s response to service; and
o For recipients receiving services via telemedicine, electronically recorded information of
direct, consultative or collateral clinical interviews.
Medical services documentation that includes:
o Laboratory, x-ray, and other findings related to the member’s physical and behavioral health
care;
o The member’s treatment plan related to medical services;
o Physician orders;
o Requests for service authorizations;
o Documentation of facility-based or inpatient care;
o Documentation of preventative care services;
o Medication record, when applicable; and
o Documentation of Certification of Need (CON) and Re-Certification of Need (RON), (see
Chapter 13.0 – Securing Services and Prior Authorization) when applicable.
• Reports from other agencies that include:
o Reports from providers of services, consultations, and specialists;
o Emergency/urgent care reports; and
o Hospital discharge summaries.
• Paper or electronic correspondence that includes:
o Documentation of the provision of diagnostic, treatment, and disposition information to the
PCP and other providers to promote continuity of care and quality management of the
recipient’s health care;
o Documentation of any requests for and forwarding of behavioral health record information.
• Financial documentation that includes:
o Documentation of the results of a completed Title XIX/XXI screening as required in Chapter
2.0, Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug
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Coverage and Low Income Subsidy Program; and,
o Information regarding establishment of any copayments assessed, if applicable (see Chapter
8.0, Copayments).
Legal documentation including;
o Documentation related to requests for release of information and subsequent releases
o Copies of any advance directives or mental health care power of attorney as defined in
Chapter 10.0, Advance Directives, if applicable, including:
 Documentation that the adult person was provided the information on advance
directives and whether an advance directive was executed
 Documentation of authorization of any health care power of attorney that appoints a
designated person to make health care decisions (not including mental health) on
behalf of the person if they are found to be incapable of making these decisions;
 Documentation of authorization of any mental health care power of attorney that
appoints a designated person to make behavioral health care decisions on behalf of
the person if they are found to be incapable of making these decisions.
Documentation of general and informed consent to treatment pursuant to Chapter
2.6, General and Informed Consent to Treatment and Chapter 2.7, Pharmacy
Management;
 Authorization to disclose information pursuant to Chapter 16.0, Confidentiality; and,
 Any extension granted for the processing of an appeal must be documented in the
case file, including the Notice regarding the extension sent to the recipient and
his/her legal guardian or authorized representative, if applicable (see Chapter 20.0,
Title XIX/XXI Notice and Appeal Requirements).
MEDICAL RECORD MAINTENANCE
Providers must retain the original or copies of member medical records as follows:
• For an adult, for at least six (6) years after the last date the adult member received medical or health
care services from the provider; or
• For a child, either for at least three (3) years after the child’s eighteenth birthday or for at least six (6)
years after the last date the adult member received medical or health care services from the
provider, whichever occurs later.
The maintenance and access to the member medical record shall survive the termination of a
Provider’s contract with Health Choice Integrated Care, regardless of the cause of the termination.
PCP MEDICATION MANAGEMENT AND CARE COORDINATION WITH BEHAVIORAL HEALTH
PROVIDERS
When a PCP has initiated medical management services for a member to treat depression, anxiety,
and/or ADD/ADHD, and it is subsequently determined by the PCP or Health Choice Integrated Care that
the member should receive care through the behavioral health system for evaluation and/or continued
medication management services, Health Choice Integrated Care will require and assist the PCP with
the coordination of the referral and transfer of care. The PCP will document in the medical record the
care coordination activities and transition of care. The PCP must document the continuity of care. (See
Chapter 11.1, Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare
Providers.)
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MEDICAL RECORD AUDITS
Health Choice Integrated Care conduct routine medical record audits to assess compliance with
established standards. Medical records may be requested when Health Choice Integrated Care is
responding to an inquiry on behalf of a member or provider, administrative responsibilities quality of
care issues, and/or DBHS monitoring and validation audits Providers must respond to these requests
within fourteen (14) days or in no event will the date exceed that of any government issues request date.
Medical records must be made available to AHCCCS/DBHS for quality review upon request. Health
Choice Integrated Care shall have access to medical records for the purpose of assessing quality of care,
conducting medical evaluations and audits, and performing utilization management functions.
TRANSITION OF MEDICAL RECORDS
Transfer of the behavioral health member’s medical records due to transitioning of the behavioral
health member to a new T/RBHA and/or provider (see Chapter 11.0 – Inter-RBHA Coordination of Care
for additional information on Inter-T/RBHA transfers), it is important to ensure that there is minimal
disruption to the behavioral health recipient’s care and provision of services. The behavioral health
medical record must be transferred in a timely manner that ensures continuity of care.
Federal and state law allows for the transfer of behavioral health medical records from one provider to
another, without obtaining the member’s written authorization if it is for treatment purposes (45 C.F.R.
§ 164.502(b), 164.514(d) and A.R.S. 12-2294(C)). Generally, the only instance in which a provider must
obtain written authorization is for the transfer of alcohol/drug and/or communicable disease treatment
information see Chapter 16.0 – Confidentiality for other situations that may require written
authorization.
The original provider must send that portion of the medical record that is necessary to the continuing
treatment of the behavioral health recipient. In most cases, this includes all communication that is
recorded in any form or medium and that relate to patient examination, evaluation or behavioral health
treatment. Records include medical records that are prepared by a health care provider or other
providers. Records do not include materials that are prepared in connection with utilization review, peer
review or quality assurance activities, including records that a health care provider prepares pursuant to
section A.R.S. § 36-441, 36-445, 36-2402 and 36-2917.
Federal privacy law indicates that the Designated Record Set (DRS) is the property of the provider who
generates the DRS. Therefore; originals of the medical record are retained by the terminating or
transitioning provider in accordance with DISCLOSURE OF RECORDS of this chapter. The cost of copying
and transmitting the medical record to the new provider shall be the responsibility of the transitioning
provider (see the AHCCCS Contractors Operation Manual, Section 402).
REQUIREMENTS FOR COMMUNITY SERVICE AGENCIES (CSA), HOME CARE TRANIING TO HOME CARE
CLIENT (HCTC) PROVIDERS AND HABILITATION PROVIDERS
Health Choice Integrated Care requires that CSA, HCTC Provider and Habilitation Provider clinical
records to the following standards. Each record entry must be:
• Dated and signed with credentials noted;
• Legible text, written in blue or black ink or typewritten; and
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Factual and correct.
If required records are kept in more than one location, the agency/provider shall maintain a list
indicating the location of the records.
CSAs, HCTC Providers and Habilitation Providers must maintain a record of the services delivered to
each behavioral health recipient. The minimum written requirement for each behavioral health
recipient’s record must include:
• The service provided (including the code used for billing the service) and the time increment;
• Signature and the date the service was provided;
• The name title and credentials of the person providing the service;
• The recipient’s CIS identification number and AHCCCS identification number;
• Health Choice Integrated Care conducts routine audits to ensure that services provided by the
agency/provider are reflected in the behavioral health recipient’s service plan. CSAs, HCTC
Providers and Habilitation Providers must keep a copy of each behavioral health recipient’s
service plan in the recipient’s record; and
• Daily documentation of the service(s) provided and monthly summary of progress toward
treatment goals.
Every thirty (30) days, a summary of the information required in this chapter must be transmitted
from the CSA, HCTC Provider or Habilitation Provider to the recipient’s clinical team for inclusion in
the comprehensive clinical record.
ADEQUACY AND AVAILABILITY OF DOCUMENTATION
Health Choice Integrated Care and subcontracted providers must maintain and store records and data
that document and support the services provided to members and the associated encounters/billing for
those services. In addition to any records required to comply with Health Choice Integrated Care
contracts, there must be adequate documentation to support that all billings or reimbursements are
accurate, justified and appropriate.
All providers must prepare, maintain and make available to ADHS/DBHS and Health Choice Integrated
Care, adequate documentation related to services provided and the associated encounters/billings.
Adequate documentation is electronic records and “hard-copy” documentation that can be readily
discerned and verified with reasonable certainty. Adequate documentation must establish medical
necessity and support all medically necessary services rendered and the amount of reimbursement
received (encounter value/billed amount) by a provider; this includes all related clinical, financial,
operational and business supporting documentation and electronic records. It also includes clinical
records that support and verify that the member’s assessment, diagnosis and Individual Service Plan
(ISP) are accurate and appropriate and that all services (including those not directly related to clinical
care) are supported by the assessment, diagnosis and ISP.
For monitoring, reviewing and auditing purposes, all documentation and electronic records must be
made available at the same site at which the service is rendered. If requested documents and electronic
records are not available for review at the time requested, they are considered missing. All missing
records are considered inadequate. If documentation is not available due to off-site storage, the
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provider must submit their applicable policy for off-site storage, demonstrate where the requested
documentation is stored and arrange to supply the documentation at the site within 24 hours of the
original request.
Health Choice Integrated Care’s failure to prepare, retain and provide to ADHS/DBHS adequate
documentation and electronic records for services encountered or billed may result in the recovery
and/or voiding not to be resubmitted) of the associated encounter values or payments for those
services not adequately documented and/or result in financial sanctions to the provider and Health
Choice Integrated Care.
Inadequate documentation may be determined to be evidence of suspected fraud or program abuse that
may result in notification or reporting to the appropriate law enforcement or oversight agency. These
requirements continue to be applicable in the event the provider discontinues as an active participating
and/or contracted provider as the result of a change of ownership or any other circumstance.
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